A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?

Rinse your mouth with hydrogen peroxide.

Brush your teeth for 60 seconds twice daily.

Floss your teeth gently following each meal.

Wear your dentures only during meals.

None

Answer and Explanation

The Correct Answer is C

Choice A: Rinse your mouth with hydrogen peroxide

Rinsing the mouth with hydrogen peroxide is not recommended for clients with mucositis. Hydrogen peroxide can be too harsh and may cause further irritation to the already sensitive mucosal lining. It is generally advised to use mild rinses such as saline or baking soda solutions.

Choice B: Brush your teeth for 60 seconds twice daily

While brushing is important, it should be done gently with a soft-bristled toothbrush, and the timing should be based on patient tolerance rather than a strict 60-second rule.

Choice C: Floss your teeth gently following each meal

Gentle flossing helps remove food particles and bacteria, reducing the risk of infection. However, if bleeding occurs, the patient should stop and consult a healthcare provider.

Choice D: Wear your dentures only during meals

Wearing dentures only during meals might be advisable for some clients with mucositis, as wearing them all day could irritate the inflamed oral tissues. However, it’s important for the dentures to fit properly and for the client to have periods of rest without the dentures to allow the oral tissues to heal.

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Correct Answer is B

Explanation

Choice A reason : Pressing down on the orbital area of the eye is not a recommended method for eliciting a response from a painful stimulus in an unresponsive patient due to the potential for injury to the eye.

Choice B reason : Pressing down on the trapezius muscle is an acceptable method for eliciting a response from a painful stimulus in an unresponsive patient. This technique is less invasive and can be performed safely to assess the patient's level of consciousness or response to pain without causing harm⁸.

Choice C reason : Using a 25-gauge needle is not an appropriate method for eliciting a response from a painful stimulus in an unresponsive patient. This could cause unnecessary harm and is not a standard practice in clinical settings.

Choice D reason : Eliciting a reflex with a reflex hammer is a method used to assess reflexes, not to elicit a response from a painful stimulus in an unresponsive patient. This tool is used to test neurological function and reflex integrity, not to assess pain response.

A. Epithelialization at the site B. Severe pain at the site C. Edema at the site D. Blistering at the site

Correct Answer is C

Explanation

Choice A reason: Epithelialization at the site of a major full-thickness burn would not be expected 12 hours post-injury. Epithelialization is a later stage of wound healing where new skin cells form and cover the wound. In full-thickness burns, this process is significantly delayed and typically requires skin grafting for wound closure.

Choice B reason: Severe pain is not typically associated with full-thickness burns due to the destruction of nerve endings in the skin. However, there may be severe pain in the surrounding areas that have sustained less severe burns.

Choice C reason: Edema is a common and expected finding at the site of a major full-thickness burn 12 hours post-injury. The inflammatory response to the burn injury leads to increased vascular permeability and fluid shift from the intravascular to the interstitial space, resulting in edema.

Choice D reason: Blistering is characteristic of partial-thickness burns (second-degree burns) but not full-thickness burns (third-degree burns). In full-thickness burns, the skin is destroyed to the point where blisters do not form.

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A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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